Preconception care: Aboubakr Elnashar


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Preconception care: Aboubakr Elnashar

  1. 1. 1 Preconception Care Aboubakr Elnashar Prof Obs Gyn, Benha University Hospital, Egypt Aboubakr Elnashar
  2. 2. 2 • Duration of pregnancy is no longer “9” months, it’s “12” months ACOG& AAP: prenatal care before conception • PCC: Concept has evolved over the last several decades Form of primary care& prevention 12 NOT 9 Aboubakr Elnashar
  3. 3. 3 Outline • Definition& Goals • Why Do We Need PCC? • Components • Scientific Evidence • Current Recommendations • Barriers • Implementation Aboubakr Elnashar
  4. 4. 4 Definition A set of interventions that aim to identify& modify (biomedical, behavioral& social) risks to a woman’s health or pregnancy outcome through prevention& management (CDC, 2006) Aboubakr Elnashar
  5. 5. 5 Goal • Goal should be realistic Identify pre-existing conditions that may affect an anticipated pregnancy Intervention(s) that could lead to more favorable outcome Aboubakr Elnashar
  6. 6. 6 Why? Aboubakr Elnashar
  7. 7. 7  Currently:  Poor pregnancy outcomes  Women enter pregnancy “at risk” for adverse outcomes  We intervene too late  There is consensus that:  Intervening before pregnancy: improve outcomes Aboubakr Elnashar
  8. 8. 8 Early ANC is too late 1. To Prevent Some Birth Defects Critical period of teratogenesis: D17 to D56 Heart: begins to beat at 22 ds after conception Neural tube: closes by 28 ds after conception Palate: fuses at 56 ds after conception 2. To Prevent Implantation Errors 3. To restore allostasis: Maintain stability through change An important objective of PCC is to restore allostasis to women’s health before pregnancy Aboubakr Elnashar
  9. 9. 9 Critical Periods of DevelopmentCritical Periods of Development 4 5 6 7 8 9 10 11 12 Weeks gestation from LMP Central Nervous SystemCentral Nervous System HeartHeart ArmsArms EyesEyes LegsLegs TeethTeeth PalatePalate External genitaliaExternal genitalia EarEar Missed Period Mean Entry into ANC Most susceptible time for major malformation Aboubakr Elnashar
  10. 10. 10 From Anticipation& Management to Health Promotion& Prevention From Healthy Mothers Healthy Babies to Healthy Women Healthy Mothers Healthy Babies Paradigm Shift Aboubakr Elnashar
  11. 11. 11 Components CDC, 2007 I. Risk Assessment II. Health promotion III. Interventions Aboubakr Elnashar
  12. 12. 12 A. Risk assessment I. Reproductive life plan: If she plans to have children? How long she plans to wait until she becomes pregnant? Plan, based on: her values& resources, to achieve those goals Aboubakr Elnashar
  13. 13. 13 II. History 1. Reproductive history: Previous adverse outcomes: infant death, fetal loss, birth defects, low birth weight, PTL 2. Medical history: Rheumatic heart disease Thromboembolism Autoimmune diseases Hypertension Diabetes Aboubakr Elnashar
  14. 14. 14 3. Medication use: Current medication  Avoid FDA Category X: Estrogen, androgens,Aminopterin, isotretinoin,Thalidomide Category D: Phenytoin, valporic acid, diazepam, Imipramine, captopril, thiazides, Spironolactone, coumarine, chlorpropamide, Progestins, tetracyclin, streptomycin, Quinine, methotrexate, vinblastin, Azathioprine. unless maternal benefits outweigh fetal risks; Over-the-counter medications, herbs& supplements Aboubakr Elnashar
  15. 15. 15 4. Substance abuse: Tobacco Alcohol Drug use 5.Toxins& teratogenic agents: At home, in the neighborhood, in the workplace: heavy metals, solvents, pesticides, endocrine disruptors, allergens Aboubakr Elnashar
  16. 16. 16 II. Physical examination: 1. Nutritional assessment: Assess the ABCDs of nutrition: anthropometric factors (e.g., BMI) biochemical factors (e.g., anemia) clinical factors dietary risks 2. Focus on Periodontal, thyroid, heart, breast, pelvic examination Aboubakr Elnashar
  17. 17. 17 III. Screening 1. Infections &immunizations: Screen for periodontal, urogenital & STD as indicated; Update immunization with hepatitis B, rubella, varicella, Tdap,HPV& influenza vaccines as needed Aboubakr Elnashar
  18. 18. 18 2. Genetic screening: Based on: family history ethnic background age Offer cystic fibrosis& other carrier screening as indicated Aboubakr Elnashar
  19. 19. 19 3. Psychosocial: Screen for depression, anxiety, domestic violence major psychosocial stressors Aboubakr Elnashar
  20. 20. 20 4. Laboratory testing: Testing should include CBC; urinalysis; blood type& screen When indicated screen for Rubella, syphilis, hepatitis B,HIV, gonorrhea, chlamydia Diabetes Thyroid Dysfunction Cervical cytology Aboubakr Elnashar
  21. 21. 21 B. Health promotion 1. Family planning:  Based on the patient’s reproductive life plan  Effective contraceptive use  Discuss emergency contraception Aboubakr Elnashar
  22. 22. 22 2. Healthy weight & nutrition: Ideal BMI: 20 to 26.0 kg/m2 Exercise Nutrition Macro& micronutrients: Getting “five a-day”: 2 servings of fruit +3 servings of vegetables  Daily multivitamin that contains folic acid Aboubakr Elnashar
  23. 23. 23 3. Healthy behaviors: Nutrition Exercise, Safe sex Effective contraceptive use Dental flossing Preventive health services Discourage risky behaviors: Douching Not wearing a seatbelt, Smoking: use the five A’s [Ask, Advise, Assess, Assist, Arrange] for smoking cessation Alcohol Substance abuse Aboubakr Elnashar
  24. 24. 24 4. Healthy environments: Discuss household, neighborhood& occupational exposures to heavy metals, organic solvents, pesticides, endocrine disruptors& allergens; Give practical tips such as how to avoid exposures Aboubakr Elnashar
  25. 25. 25 5. Stress resilience: Promote nutrition, exercise, sufficient sleep, and relaxation techniques; Address ongoing stressors (e.g., domestic violence) Identify resources to help the patient develop problem solving and conflict-resolution skills, positive mental health, and strong relationships 6. Interconception care: Promote breastfeeding, placing infants on their backs to sleep to reduce the risk of sudden infant death syndrome, positive parenting behaviors, and the reduction of ongoing biobehavioral risks Aboubakr Elnashar
  26. 26. 26 C. Interventions 1. Folic acid supplementation Reduces NTD by two thirds. 2. Rubella vaccination protection against congenital rubella syndrome. 3. Hepatitis B vaccination for at risk women:  Prevents transmission of infection to infants  Eliminates the risks to the women of hepatic failure, liver carcinoma, age cirrhosis& death due to HBV infection. Aboubakr Elnashar
  27. 27. 27 4. Diabetes management: reduces birth defects among infants of diabetic women. 5. Hypothyroidism: protects proper neurological development. 6. HIV/AIDS screening:  Allows for timely treatment  Provides women (or couples) with additional information that can influence the timing of pregnancy& treatment. Aboubakr Elnashar
  28. 28. 28 7. STD screening& TT  Reduces the risk of ectopic pregnancy, infertility, chronic pelvic pain associated with Ct& NG  Reduces risk to a fetus of fetal death or physical& developmental disabilities, including mental retardation& blindness. 8. Maternal PKU management: Prevents babies from being born with PKU-related mental retardation. Aboubakr Elnashar
  29. 29. 29 9. Switching women off Oral anticoagulant: avoids harmful exposure. 10. Antiepileptic drug: Changing to a less teratogenic tt reduces harmful exposure. 11. Accutane (isotretinoin) use management: Preventing pregnancy for women who use OR Stop before conception :eliminates harmful exposure. Aboubakr Elnashar
  30. 30. 30 12. Smoking cessation: Prevent: PTL low birth weight other adverse perinatal outcomes. 13. Eliminating alcohol use Prevents fetal alcohol syndrome other alcohol-related birth defects. 14. Obesity control: Reduces the risks of NTD, PTL, DM, CS, Hypertension Thromboembolic diseaseAboubakr Elnashar
  31. 31. 31 PPC for men • Alcohol May be associated with physical& emotional abuse May decrease fertility • Genetic Counseling • Occupational Exposure - lead • STD – Syphilis, herpes, HIV Aboubakr Elnashar
  32. 32. 32 Scientific Evidence Does PCC work? Aboubakr Elnashar
  33. 33. 33 There is evidence that individual components of PCC work: • Rubella vaccination • HIV/AIDS screening • Management and control of: – Diabetes – Hypothyroidism – PKU – Obesity • Folic Acid supplements (level 2) • Avoiding teratogens: – Smoking – Alcohol (level 2) – Oral anticoagulants – Accutane Aboubakr Elnashar
  34. 34. 34 Clinical Practice Guidelines Aboubakr Elnashar
  35. 35. 35 Clinical practice guidelines for PCC of specific maternal health conditions have been developed by professional organizations: • American Diabetes Association (Diabetes -2004) • American Association of Clinical Endocrinologists (Hypothyroidism – 1999) • American Academy of Neurology (Anti-epileptic drugs) • American Heart Association/American College of Cardiologists (Anti-epileptic drugs - 2003) Aboubakr Elnashar
  36. 36. 36 ACOG/AAP (2002) All health encounters during a woman’s reproductive years, particularly those that are a part of PCC should include counseling on appropriate medical care and behavior to optimize pregnancy outcomes. ACOG/AAP Guidelines for perinatal care, 5th edition, 2002 Aboubakr Elnashar
  37. 37. 37Aboubakr Elnashar
  38. 38. 38 USPHS “Every woman (and, when possible, her partner) contemplating pregnancy within one year should consult a prenatal care provider. Because many pregnancies are not planned, providers should include preconception counseling, when appropriate, in contacts with women and men of reproductive age….Such care should be integrated into primary care services.” USPHS Expert Panel on the Content of Prenatal Care, 1989 Aboubakr Elnashar
  39. 39. 39 Barriers Aboubakr Elnashar
  40. 40. 40 I. Patient Aspects • High rate of unintended pregnancies • Ignorance about importance of good health habits prior to conception • Limited access to health services in general. Aboubakr Elnashar
  41. 41. 41 II. Provider Aspects • Feeling of having inadequate knowledge • Perception of PCC being time consuming • Lack of awareness of how to integrate PCC into practice • Concern about insurance reimbursement. Aboubakr Elnashar
  42. 42. 42 III. Other barriers: • Availability of contraceptives • Health Insurance Coverage • Out of Pocket Expenses. Aboubakr Elnashar
  43. 43. 43 Implementation Aboubakr Elnashar
  44. 44. 44 Who Should Get PCC? • PCC should be provided to all reproductive age individuals Aboubakr Elnashar
  45. 45. 45 WHO TO PROVIDE? – OB-GYNs – Pediatricians, Family Medicine, Internists, – Nurses – Genetic Counselors – Health Educators Aboubakr Elnashar
  46. 46. 46 Why Should Ob/Gyns be Concerned with PCC? • OB/GYN’s  have the most frequent contact with women of childbearing age  are aware of prior poor pregnancy outcomes  Responsible for ANC  already have the knowledge& are applying it  advantage to improve pregnancy outcomes Aboubakr Elnashar
  47. 47. 47 How PCC can be Integrated into Practice? I. OB-GYNs 1. WHC: - Our best opportunity - Single or multiple visits - Ask about reproductive life plan - If she plans to have child in next 1-2 yrs: she& husband should return for full visit. 2. Negative pregnancy test: an opportunity for PCC 3. Family planning encounter 4. Infertility evaluation 5. Following a poor pregnancy outcome Aboubakr Elnashar
  48. 48. 48 Thank you CONCLUSION “PCC is the cornerstone of healthy infants, children, families& communities Yhank you Aboubakr Elnashar